control and performance measurement. How has this played out in Australia and the Netherlands? During the 1990s in Australia, new organisations were established that fragmented the profession to some extent, and a number of challenges to the medical profession have come from governments, insurers and health service delivery organisations in the search for ways to contain costs. But these do not represent a general loss of authority by the profession (Lewis, 2014). In the Netherlands, the state reconfigured its corporatist relationships in the 1990s in order to reduce the number and size of the bodies involved in policy-making, and to eliminate stakeholder representation. This reduced the ability of provider (including professional) interests to intervene at multiple points, as is illustrated by the relatively easy passing of the 2006 Health Insurance Law (Okma and de Roo, 2009). However, the Dutch consensual style of policy-making (the Polder Model) has not disappeared and the state–medicine relationship in the Netherlands remains strong through neo-corporatist structures. The manipulation of state–profession relationships is clear to a greater degree in the Dutch case than in Australia, reflecting the more integrated state–profession relationship and broader corporatist structures in the Netherlands, and the more separated position of the medical profession in Australia. Ideation Ideation is used here to refer to a policy paradigm as an overarching set of ideas that specifies how problems are perceived, which goals might be attained and what techniques can be used to reach them. Individuals with conflicting policy positions still share understandings and a more realistic view of the sector they are interested in. Ideas are important in policy change in three ways (see Béland, 2010): they help define the social and economic issues of the day; they are important as assumptions (paradigms) that guide the development and selection of policy choices; and they are an important framing device that helps actors legitimise policy decisions. Struggles over health policy clearly involve ideas about health that support particular actors and shape the range of possible policy options. There is an obvious link between the power of the medical profession and how health is conceived (Lewis, 2005). What are the fundamental assumptions about health? The dominant paradigm is biomedicine, which sees the human body as a machine that sometimes breaks down and needs to be fixed. This leaves little room for the social, psychological and behavioural dimensions of illness. The ‘social determinants of health’ approach poses a challenge to biomedicine as the dominant idea underpinning the sector. This focuses on addressing the social, economic and cultural conditions that produce ill health, and it has been emerging since the 1970s. It casts health as a product of society rather than of individual attributes and behaviours. The World Health Organization (WHO) began calling for a reorientation towards disease prevention and health promotion strategies in the 1970s. In the late 1990s and early 2000s, policy in some nations began to emphasise that the multiple influences on health from the social and environmental contexts are crucial, with inequities in society contributing significantly to unequal health outcomes. Mo d e l s o f g o v e r n a n c e f o r t h e h e a l t h s e c t o r In Australia, there is mostly a reliance on the restoration of health or curative care. Apart from the introduction of community health programmes in Australia in the 1970s, there has been relatively little that suggests a national-level agenda to move away from traditional, biomedical concerns, towards more inclusive and societal-based approaches to health policy (Lewis, 2014). A national preventative health agency was established in 2011 as a partnership of federal government, state governments and the private sector, but it focused on strengthening individual responsibility for prevention. A stronger sign of a socialdeterminants approach was the application of the WHO’s (2005) framework to the Australian context of ‘closing the gap’ – an initiative to improve the situation of indigenous Australians. However, the national government elected in 2013 abolished the national prevention agency and the partnership agreement (Lewis, 2014). In the Netherlands, there is scant evidence of discussions about health promotion and the social determinants. Private health insurers have made little progress on this front, focusing instead on acute hospital services (Stoelwinder, 2008). This is likely related to preventive health care being mainly provided by public health services. In addition, disease prevention, health promotion and health protection fall under the municipalities (Schäfer et al., 2010). In summary, the challenges to biomedicine over the last four decades from the social determinants of health have been muted in both Australia and the Netherlands. There have been some visible attempts at the national level in the Australian case, particularly in relation to indigenous Australians. The lack of visibility of this in the Dutch case likely reflects that it largely falls outside national policy, although perhaps it does not sit easily in a context where social solidarity is regarded as the norm. Conclusion Existing institutions, different political systems and societal traditions strongly shape governance change. Two different versions of incremental policy adjustments are neatly illustrated by the case of insurance changes, with the Dutch moving steadily in one direction while Australia oscillates one way and then the other. Changes to the state–profession relationship are larger in the Dutch than the Australian case, reflecting the more integrated role of the professions. Australia has (sporadically and to a small extent) embraced the need for a social-determinants approach to health, while the Netherlands has paid little attention to this, at least at the national level. This study of governance change in the health sector demonstrates how two nations, faced with similar challenges but founded on different institutions, politics and ideas, respond differently. JENNY M. LEWIS is professor of public policy in the school of social and political sciences at the University of Melbourne, and is an Australian Research Council future fellow for 2013–16. Lewis is a public policy expert with particular interests in governance, policy influence and the policy process. She has published widely in journals, is the author of four books and has been awarded American, European and Australian prizes for her research. Her most recent book, Academic Governance: Disciplines and Policy, was published by Routledge in 2013. Commonwealth Health Partnerships 2015 113
Commonwealth Health Partnerships 2015
To see the actual publication please follow the link above